THORACIC TRAUMA study questions
Continued transfusions to maintain hemodynamic stability Penetrating chest wound medial to nipple, medial to scapula >=1500 mL out upon chest tube insertion >200 mL/hr blood evacuated in 2-4 hours Hemodynamic instabillity, SBP <80mmHg despite aggressive blood/volume resuscitation
Indications for urgent exploratory thoracotomy in the presence of a massive hemothorax
Penetrating - 80-90% of stab wounds to the heart show evidence of tamponade
Is pericardial tamponade more likely from blunt or penetrating trauma?
Active bleeding large expanding hematoma distal ischemia bruit/thrill
List the hard signs of penetrating neck injury
Zone 1: Base of neck from clavicle to cricoid cartilage Zone 2: Cricoid cartillage to inferior mandible Zone 3: Inferior mandible to base of skull
List the landmarks for the zones of the neck
Shock responding to fluid resuscitation Small stable hematoma Associated nerve injuries dyspnea sub Q emphysema hoarsness dysphagia minor hematoemesis
List the soft signs of penetrating neck injury
RR <8 or >35 PaO2 <60 @ 50% FiO2 PaCO2 or EtCO2 >50 @ 50% FiO2
List three clinical signs of progressive fatigue and deterioration that should prompt intubation and mechanical ventilation in a patient with a flail chest
Contused lung produces more interstital and intra-alvolear fluid resulting in IMPAIRED GAS EXCHANGE
The most significant life-threat with a flail chest is the accompanying damage to the lung parenchyma: pulmonary contusion. Why is this detrimental?
Empyema
A complication of a pneumo/hemothorax resulting in an infection in the pleural cavity called ...
Tension pneumothorax
A leak from the lung to chest cavity, build up of pressure in cavity and lung collapses is called a ...
ED thoracotomy
A patient sustaining a penetrating wound, who has required CPR int he pre-hospital setting, should be evaluated for any signs of life. If there are none and no cardiac activity is present, all further interventions including __________ should be held?
Pericardial tamponade
Beck's triad symptoms can indicate ...
Thready/absent peripheral pulses (PEA) Diaphoresis Pale/cyanotic/cold extremities Decreased LOC/Agitation Tachycardia or Tachypnea Pulsus Paradoxus
Besides Beck's triad, what are physical assessment findings in pericardial tamponade?
Commotio cordis
Blow to the chest producing cardiac arrest
Tracheobronchial disruption
Blunt or penetrating injury near cricoid ring and carina leading to crepitus under skin of neck and face is called ...
Tracheobronchial tree injury
Blunt or penetrating trauma resulting in an injury that is usually fatal at the scene secondary to asphyxia. Usually from a compressive injury from a seat belt or steering wheel.
Heart
Chest trauma that impairs perfusion
Lungs
Chest trauma that impairs ventillation
tension pneumothorax
Clamping a chest tube with a continuing air leadk may result in a ...
2 or more ribs brokein in 2 or more places, creating "floating" areas. Free section moves opposite way as the other areas
Define flail chest
Prepare for OR Chest tube insertion Auto transfusion If intubated, increase peak pressures
Describe the appropriate resuscitative management of a pateint with a massive hemothorax
4th and 5th ICS between midaxillary and anterior axillary lines
Describe the preferred placement of a chest tube
Accompanying pulmonary contusions leads to increased interstitial and intra-alvolear fluid leading to impaired gas exchange
What is the etiology of the severe hypoxia that may accompany flail chest?
Burping or removing the dressing Needle decompression
What is the immediate resuscitative intervention for an open pneumothorax?
Impaired gas exchange leading to profound hypoxia
What is the mechanism of death from an open pneumothorax
Deceleration Motor vehicle ejection death in same vehicle Falls from height Auto deformity Aircraft crashes
What is the mechanism of injury for blunt injury to the aorta?
2nd to 3rd intercostal, mid-clavicular line -or- 4th to 5th intercostal, mid-axillary line
What is the preferred landmark when performing a needle decompression?
Epidural catheter Paravertebral analgesia (NO narcotics that decrease RR)
What is the preferred route of main medication administration for a patient with a flail chest?
Thoracotomy -definitive surgical repair Pericardialcentesis -emergent tx, evacuate pericardial blood and clots and control bleeding
What is the recommended management for a pericardial tamponade?
Hypotension Coronary hypoperfusion
What is the shared mechanism of death in both a tension pneumothorax and a pericardial tamponade?
Fixation point of descend aorta at ligamentus arteriousum causes a tear
What is the site of injury for blunt injury to the aorta?
Watch for Beck's triad Needle decompression CXR Pericardialcentesis ETCO2 watch for cardiac tamponade
What medical/nursing interventions should be performed on this patient?
CPAP
What non-invasively ventilatory support intervention should be included in the regimen of a patient with a flail chest?
Dull or flat
What percussion note should be anticipated over a massive hemothorax?
Amount and nature of drainage Normal tidling in collection chamber Continuous bubbling (air leak in lung)
What should a TNS monitor with respect to the chest tube drainage device?
CXR Angoigraphy (artography) CT MRI TEE
What tests may be used to diagnose aortic injury?
Pulsus paradoxus
When SBP decreases >10 mmHg with inspiration, it is known as ...
Creatinine phosphokinase with isoenzymes
Which lab value should NOT be used to screen for blunt cardiac injury patients?
Cardiac arrest (commotio cortis) Patient may have non-specific chest pain Can lead to complications - cardiac tamponade, constrictive pericarditis, valvular rupture
Why can a blunt cardiac injury be life threatening?
Tension pneumothorax
Why can a patient with an open pneumothorax have absent breath sounds on both sides of the chest?
To promote pulmonary hygiene, splinting, atelectasis, hypoxia, hypoventillation
Why is pain management essential for a patient with a flail chest?
No-it releives the pressure, but needs positive pressure in the lung to expand
Will pleural decompression re-establish bilateral breath sounds?
Yes - Relieving the pressure will allow for venous return
Will pleural decompression re-establish radial pulses?
Hemothorax Pneumothorax
Flail chest is a red flag for significant underlying intrathoracic injury, usually pulmonary contusion. What other injuries should be suspected?
"paper bag syndrome" Fractured rib penetrating lung parenchyma
How can a patient develop a closed (simple) pneumothorax from a blunt chest trauma?
1500 mL or more
How much blood constitutes a massive hemothorax?
Massive blood transfusion Needle decompression
How should this patient be resuscitated?
Pleuritic chest pain-severe Respiratory distress JVD Sub-Q emphysema distant heart sounds Tracheal deviation Hyperresonance on the affected side Absent or decreased breath sounds asymmetric chest movements
What are the major clinical signs and symptoms that suggest a tension pneumothorax?
right ventricle
What chamber of the heart is most vulnerable to developing a blunt cardiac injury?
Agitation Tachypnea JVD cyanosis diaphoresis tachycardia hypotension narrowed pulse pressure
What clinical s/sx are shared by a tension pneumothorax and pericardial tamponade?
Absent breath sounds
What clinical sign differentiates a tension pneumothorax from a pericardial tamponade?
Respiratory status Lung sounds Vital signs Chest X-ray Pain Clinical presentation
What clinical signs and symptoms should a TNS monitor following chest tube insertion?
Decreased PaO2 Decreased SpO2 Decreased lung compliance decreased tidal volume and vital capacity Decreased venous return
What clinical signs and symptoms suggest that the complication of a flail chest is present?
Cardiac arrest Cardiac tamponade decreased cardiac output fibrosis empyema
What complications could this patient sustain?
Hypotension JVD Muffled heart tones
What constellation of signs are known as Beck's triad?
Chlorhexidine 10-14 Ga LONG catheter /Turkel needle
What equipment must be prepared if a physician is going to perform a needle decompression?
Acute cardiac tamponade >=1500mL chest tube drainage check chest tube drainage penetrating wounds medial to nipple and scapula SBP <80 continue blood transfusions/products
What factors determine the need for an urgent thoracotomy?
Chest pain radiating to the back respiratory distress S/Sx of pericardial tamponade Steering wheel imprint Hematoma at thoracic outlet Upper extremity hypertension or BP differential in arms interscapular murmur Palpable fractures of sternum ro thoracic spines
What findings on a physical exam should cause a TNS to have a high index of suspicion for blunt injury to the aorta with an intimal tear resulting in false aneurysm formation?
CXR Labs ABGs serial H&Hs
What further diagnostic workup does this patient need?
Tension pneumothorax Open pneumothorax Flail chest
What immediate life threats must be found during the "B" phase of the primary survey?
Rib fx lung parynchymal injury intercostal/internal mammary injuries Hilar injury Great vessel injury Cardiac laceration Diaphragmatic tear splenic lac liver lac
What injuries could precipitate a massive hemothorax?
Neck and great vessel injury (subclavian artery/vein, aortic injury)
What internal injuries should be suspected if a patient presents with fractures to the 1st and 2nd ribs?
Chest tube to 4th, 5th intercostal space, anterior to midaxillary line -or- Observation for asymptomatic injuries
What intervention is indicated for a closed (simple) pneumothorax?
Impaired gas exchange leading to profound hypoxia
What is a major life threat from an open pneumothorax?
